Former and current CU Cancer Center Directors, Bunn and Schulick, describe how research and philanthropy will beat cancer

In the years since Richard Nixon
signed the National Cancer Act in 1971, the overall five-year survival rate for
patients diagnosed with the disease has risen from about 50 percent to almost
70 percent. Adding the influence of improved cancer prevention (especially the
more than 50 percent reduction in smoking since 1964), combined with better
screening and better therapies, makes an overall decrease in the cancer death
rate of 27 percent just since 1995. Here, for May’s Cancer Research Month, we
speak with University of Colorado Cancer Center Founding Director, Paul Bunn,
MD, and current CU Cancer Center Director, Richard Schulick, MD, MBA about the
innovations that have driven these improvements and the challenges that remain
for the future of cancer research and treatment.

CU Cancer Center: Let’s
start with a simple question – what do we know now that we didn’t know then?

Bunn: Well, in
1971 when Richard Nixon signed the National Cancer Act the expectation was that
cancer would go away by 1980 or so. What we know now is that it takes a long
time to go from a basic discovery to a prevention or treatment strategy.

Schulick: In
the 1970s we were trying to figure out things we take for granted now. What we
call “cancer” is hundreds or even thousands of related diseases, defined more
by the genetic changes that create them than where they live in the body. And tumors
themselves are more complex than we imagined – a single human tumor can have
300 mutations or genetic changes. In the 1970s we didn’t know any of these
genes; now we know some of them. One
thing hasn’t changed: Research was hard in the 1970s, it’s hard today, it will
always be hard.

CU Cancer Center: In
addition to understanding more about the biology of cancer, has the way we go about cancer research changed?

Bunn: When
chemotherapy came along in the 1940s, it came from plants and plant alkaloids –
the government was screening thousands of natural compounds to see what would
kill cancer cells. But that screening approach didn’t work. We didn’t stumble
onto a cure. Now we know that the chance you’re going to find something without
science is very low.

CU Cancer Center: Are
there examples of drugs or techniques that are based on this ground-up approach
of starting with the science?

Bunn: People think
it’s all new drugs, but the fact is that even radiation and surgery are nothing
like they used to be.

Schulick: But
in terms of new drugs or treatments, even 10 or 15 years ago people would have
said that immunotherapy was dead – that it was an idea that didn’t work out. It
was understanding things like how tumor cells hide from the immune system, or
how to engineer immune system cells to attack cancer cells, that have made
immunotherapy a revolutionary treatment for many forms of cancer.

Bunn: Also,
targeted therapies are designed from the ground-up. You find a genetic change driving
a certain subtype of cancer and then design a drug to target this change. We’ve
gotten more rational, or at least more rational than screening compounds to see
what works.

CU Cancer Center: What
do you think are the immediate goals for cancer research? What specific
knowledge or tools would allow us to continue accelerating the pace of new
treatments?

Schulick:
Actually, there’s a lot we don’t know. And even some of the things we know, we
don’t know how to use. For example, we know a lot about tumor suppressor genes
– genes that fight cancer, and that cancer often disables. In fact, mutations
in tumor suppressor genes are even more common than mutations in genes that
drive cancer. But we can’t utilize tumor suppressor genes therapeutically. This
is just one. There are plenty of gaps.

Bunn: One of the
main issues in immunology is that we don’t have good animal models that we can
use to test new treatments. Most animal models use immunocompromised mice – you
can only grow cancer in a mouse model if you first suppress the immune system.
But you can’t test immunotherapy in a model without an immune system. We need
to find good preclinical models. In addition, some patients have huge
benefit from current immunotherapy while others have little or no benefit. We
need better predictive markers before treatment to determine which patients
will benefit. And we need a better understanding of the reasons that some do
not benefit so we can improve the treatments for them.

Schulick: Even
in mice with intact immune systems, you can cure them easily but the same
treatment might not work in humans. The mice we deal with are so homogenous and
everything is controlled, you can perturb things a little bit and you get a
result. Humans are different – it’s logarithmically more complex.

CU Cancer Center: Still,
we’ve managed to make significant progress…

Bunn: For lung
cancer, survival used to be 5 percent. Now it’s 18 or 20 percent.

Schulick: For
pancreas cancer, it was three percent and now it’s eight. It is not enough to
be satisfied with, but it is a start. Unlike diseases like lung cancer or melanoma,
we don’t have an effective immunotherapy yet.

Bunn: And you
don’t have early detection.

Schulick:
Things are getting better today and will continue getting better. And the
reason we’re getting better is all the research done in the last several
decades.

CU Cancer Center: So,
it sounds like despite these gains, more work is needed. What do you see as the
challenges or barriers that keep us from moving faster against cancer?

Schulick: Look,
we’ve even lost ground in a couple cancers – uterine and cervical.

Bunn: Where we’ve
lost ground is in implementing things we know work, like HPV vaccination and
lung cancer screening. We’ve lost opportunities to detect and prevent cancer.
How is it that young people don’t get HPV vaccination that can prevent cervical
cancer and some head and neck cancers? How is it that someone at high risk for
developing lung cancer doesn’t get the recommended screening?

Schulick: Also,
cancer research has gotten more expensive. In the 1970s, to get equipment together
maybe all you really needed was a refrigerator, a centrifuge and reagents. Now
you need $10 million to buy the technology just to get started. In the 1970s a
lot less was known, so you could gain a lot of ground with a straightforward
experiment.

Bunn: The reality
is that because costs are higher than inflation and research support is not
higher, the actual value is probably less. For example, we got a SPORE grant in
lung cancer in 1992 and the dollar amount now is basically the same. Before,
everybody had four projects going on and now everybody can only afford three.

CU Cancer Center: So,
what is the path forward?

Schulick: I
like the words of our Vice Chancellor of Advancement, Scott Arthur. Scott says
that cancer research on this campus is like a rocket. But rockets need rocket
fuel. In terms of funding, NIH support has actually gone down during periods in
the last few decades, so philanthropy will have a heavy hand in the pace we
beat cancer. How fast do people want us to go? The more support we have, the
faster we can get where we want to be.

Bunn: In terms of
new things we can do, one of the most important is multidisciplinary care –
it’s incredibly important to have the pathologist, oncologist, radiation
oncologist, surgeon, radiologist and other specialties in a room together
talking about how best to approach a case. This is happening more and more at
NCI-designated cancer centers, but by and large doesn’t happen in the
community.

Schulick: I
think about our opportunities to advance cancer treatment along four lines: Prevention,
early detection, better treatments (including chemotherapy, radiation, surgery
and immunotherapy), and the fourth is pairing the right treatment with the
right patient. That last one is about bioinformatics – personalized medicine –
instead of treating all patients with, say, lung cancer, the same way, separating
them into the hundreds of cancers they really are and treating each one individually.
Instead of seeing a nail and hammering it on the head, you treat each person
differently based on obtainable information and tailored to their specific
cancer.

CU Cancer Center: Other
than philanthropy, these ideas we’ve talked about seem to involve researchers,
doctors, hospitals and governments. Is there anything regular people can do to
help cancer research?

Bunn: Sure,
there’s patient education around clinical trials. Since we started CU Cancer
Center, the number of patients entering clinical trials here has increased
every year. Now it’s between 10 and 20 percent. But nationwide only about two
percent of cancer patients go on a clinical trial.

Schulick: Ideally
every cancer patient should be in at
least one clinical trial, if not two – everyone could contribute to our
knowledge of cancer. For every patient, there’s some trial that would benefit
our knowledge of cancer.

Bunn: Clinical
trials don’t just test new drugs. There’s plenty of non-interventional trials
or other ways to get involved.

Schulick: It’s
rare that I meet a cancer patient who, after you talk to them, they don’t want
to participate. Most people after they hear that they have an opportunity to do
something for future patients and that there is a chance it could them,
personally, they’re happy to participate. One problem is that there are many
practitioners that don’t have any motivation to put patients on clinical
trials.

Bunn: Some can’t –
they don’t have the support to do it.

Schulick: And
that’s why one of our major goals is to increase access to clinical trials.
We’re the only NCI-designated comprehensive cancer center in this part of the
Rocky Mountain region. It’s our responsibility to bring our experts and
expertise closer to populations in our state and beyond who could be
participating in clinical trials.

Bunn: Right, and another
threat is that some people due to where they live or to socioeconomics are left
behind. Even on an industry-sponsored clinical trial, insurance pays for the
part that is standard of care, and sometimes insurance doesn’t want to pay. Part
of working on disparities is making sure that the fraction of patients on clinical
trials is close to the makeup of the community.

CU Cancer Center: How
do you see CU Cancer Center’s role in all this – where are we in this fight or war or Moonshot?

Schulick: We
have come a long way, but we have a very long way to go. I have to compliment
Paul on his vision of establishing a top cancer center and for all of the
accomplishments he has led and stewarded.

Bunn: The
atmosphere here is incredible. People in cancer research on this campus are
excited and they collaborate. It’s an exciting time in cancer research and
we’re right here in the middle of where it’s happening.

Schulick: Our
physical plant is, of course, never enough, but it’s pretty good. We’re
growing. Denver is an easy place to attract top talent. Our cancer center is on
an excellent trajectory.

Bunn: This campus
is a huge opportunity, especially to make a big difference with philanthropy. Philanthropy
is an important driver and it counts. It’s a huge and essential part of the
culture here.

Schulick:
There’s a time in the future we’re going to beat most cancers, but is that 50
years from now? Is it less than that? The speed at which we get there is
proportional to how much we spend on research, training, and care. The choice
is ours.